ULCERATIVE COLITIS
CONTENTS
Introduction
Epidemiology
Pathogenesis
Clinical Features
Montreal Classification
Management
Prognosis
INFLAMMATORY BOWEL DISEASE
• Represents two distinctive disorders of idiopathic chronic intestinal inflammation.
Crohn’s disease
Ulcerative colitis
• Most common time of onset of IBD is during preadolescent or adolescent era and young
adulthood.
• Bimodal distribution:
Early onset 10-20 years,
Smaller peak at 50-80 years of age.
• May begin as early as 1st year of life.
ULCERATIVE COLITIS
• Idiopathic chronic inflammatory disorder, localized to the colon sparing the upper GI
tract.
• Disease usually begins in the rectum and extends proximally for a variable distance.
• Localized to the rectum: Ulcerative Proctitis, involving the entire colon: Pancolitis
• Approximately 50–80% of pediatric patients have extensive colitis.
• Rarely noted to be present in infancy.
EPIDEMIOLOGY
• Age-specific incidence rates of pediatric UC in North America is 2/100,000
population.
• Prevalence of UC in northern European countries and the United States varies from
100 to 200/100,000 population.
• Men are slightly more likely to acquire UC than women.
Data collected from February 2017-2019 in Nepal
PATHOGENESIS
• Caused by dysregulated immune response to environmental factors in a genetically
susceptible host. Dysregulated immune response
• Environmental factors:
Alterations in the gut microbiome
Less exposure to microbes at young age
Increased use of antibiotics at younger age
• Concordance rate in twins: 16%
• pANCA positive in ~70% of patients. Environmental Genetically
factors susceptible host
CLINICAL FEATURES
• Clinical course, marked by remission & relapse.
• Mode of onset: Insidious with gradual progression of symptoms to acute and fulminant.
• Typical presentation: Blood, mucus, and pus in the stool as well as diarrhea.
• Common symptoms: Tenesmus, Urgency, Cramping abdominal pain (especially with
bowel movements), and Nocturnal bowel movements.
• Fulminant Colitis: Fever, severe anemia, hypoalbuminemia, leukocytosis, and more than
5 bloody stools per day for 5 days.
• Anorexia, weight loss, and growth failure may be present.
• Extraintestinal manifestations:
Pyoderma gangrenosum,
Sclerosing cholangitis,
Chronic active hepatitis,
Ankylosing spondylitis,
Iron deficiency
• After treatment of initial symptoms, approximately 5% of children with ulcerative
colitis have a prolonged remission (longer than 3 years).
MONTREAL CLASSIFICATION OF EXTENT AND
SEVERITY OF ULCERATIVE COLITIS
• E1 (Proctitis): Inflammation limited to the rectum.
• E2 (Left-sided; distal): Inflammation limited to the splenic flexure.
• E3 (Pancolitis): Inflammation extends to the proximal splenic flexure.
• S0 (Remission): No symptoms.
• S1 (Mild): 4 or less stools per day (with or without blood), absence of systemic
symptoms, normal inflammatory markers.
• S2 (Moderate): 4 stools per day, minimum signs of systemic symptoms.
• S3 (Severe): 6 or more bloody stools per day, Pulse rate of ≥90 beats/min, Temperature
≥37.5°C (99.5°F), Hemoglobin concentration <10.5 g/dL, ESR ≥30 mm/hr.
DIAGNOSIS
• Typical presentation in the absence of identifiable specific cause and typical endoscopic &
histologic findings.
• Laboratory Investigations:
Iron deficiency anemia
Hypoalbuminemia
Sedimentation rate & CRP often elevated
Elevated fecal Calprotectin
• Endoscopic findings:
Microulcers, which give the appearance of a diffuse abnormality.
With very severe chronic colitis, pseudopolyps may be seen.
• Histologic findings:
Gross appearance characterized by erythema, edema, loss of vascular pattern,
granularity, and friability.
Cryptitis, crypt abscesses, mucus depletion, and branching of crypts.
• Flexible Sigmoidoscopy can confirm the diagnosis.
• Colonoscopy can evaluate the extent of the disease.
TREATMENT
• Treatment is aimed at controlling symptoms and reducing the risk of recurrence with a
secondary goal of minimizing steroid exposure.
Mild/Mild to Moderate Colitis:
• First drug class to be used: 5-ASA
• Sulfasalazine: 30-100 mg/kg/day (divided into 2-4 doses)
• Mesalamine: 50-100 mg/kg/day, Balsalazide: 2.25-6.75 g/day
• 5-ASA preparations effectively treat active ulcerative colitis and prevent recurrence.
• Recommended that the medication be continued even when the disorder is in remission.
• Can also be given in enema or suppository form (useful for proctitis).
Moderate to Severe Pancolitis/Colitis unresponsive to 5-ASA:
• Treated with Corticosteroids, m/c Prednisone.
• Usual starting dose: 1-2 mg/kg/24 hr (40-60 mg maximum dose)
• Can be given once daily.
• With severe colitis, the dose can be divided twice daily and can be given intravenously.
• Effective medication for acute flares, but not appropriate for maintenance because of loss
of effects and S/Es.
• Children with disease requiring frequent Corticosteroid therapy are started on
Immunomodulators: Azathioprine (2.0-2.5 mg/kg/day) or
6-mercaptopurine (1-1.5 mg/kg/day)
• Infliximab: Effective for induction & maintenance for moderate to severe disease.
SURGERY
• Colectomy is performed for intractable disease, complications of therapy, and fulminant
disease that is unresponsive to medical management.
• Intractable/Fulminant Colitis: Total Colectomy (Ileoanal J pouch anastomosis-IPAA)
• Major complication of this operation is Pouchitis, which is a chronic inflammatory
reaction in the pouch, leading to bloody diarrhea, abdominal pain, and occasionally, low-
grade fever.
Commonly responds to treatment with oral Metronidazole or Ciprofloxacin.
PROGNOSIS
• Course of UC is marked by remissions and exacerbations.
• Most of the children respond initially to medical management.
• Many children with mild manifestations continue to respond well to medical
management and may stay in remission on a prophylactic 5-ASA preparation for long
periods.
• Beyond the 1st decade of disease, the risk of development of colon cancer begins to
increase rapidly.
REFERENCES
• Nelson Textbook of Pediatrics, 21st Edition
• Ghai Essential Pediatrics, 10th Edition
• Harrison’s Principles of Internal Medicine, 21st Edition
• [Link]
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